CSE Citizen Perception Survey on Urban Air Pollution and Mobility

What do you think about the air quality and mobility in the city you live?? Do you suffer from regular cough and cold? Do you find the traffic messy? Share your experiences with us and help us take action..fill the form given below:

Name:

Age: *

Gender:

Occupation: *

City and state: *

Email: *

Phone:

Address (optional):

Part I. Tell us about your travel and health..

How many kilometers do you travel daily to reach office/workplace? :

Your Average journey speed in km/hour :

< 10 km/h

10-20 km/h

20-30 km/h

> 30 km/h

Your Average trip length (one side):

< 2 km

2-5 km

5-10 km

> 10 km

How far do you live from the main road? (in meters):

Most used mode of transport (Public/ Personal) :

If public transport

Time generally spent waiting for bus/metro(min):

How do you reach the public transport terminals (walk/ autos/ cycle rikshaws/ own motor vehicle/ public transport)?:

Did you suffer from any respiratory disease (cough/wheezing/ common cold/ sinusitis/ rhinitis/ chest pain) in the past year: